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Health Aff (Millwood). 2019 Jun;38(6):973-980. doi: 10.1377/hlthaff.2018.05494.

Historical Mismatch Between Home-Based Care Policies And Laws Governing Home Care Workers.

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Lisa I. Iezzoni ( ) is a professor of medicine at Harvard Medical School, based at the Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, in Boston.
Naomi Gallopyn is a project manager at the Health Policy Research Center, Mongan Institute, Massachusetts General Hospital.
Kezia Scales is director of policy research at PHI, located in the Bronx, New York.


Americans generally want to remain in their homes even if they develop chronic health problems or disabilities that qualify them for nursing home care. While family members or friends provide the preponderance of home-based support, millions of Americans use paid personal assistance services (PAS). Inexorable demographic trends are increasing the numbers of people who need paid home-based PAS, with this need rapidly outstripping the capacity of the paid PAS workforce. While many factors contribute to this widening discrepancy, its roots reach back more than eighty years to asynchrony among various policies affecting home-based supports for people with functional impairments and policies affecting home-based PAS workers. Finding solutions to the growing gap between demand for the services and the PAS workforce requires policies that cut across societal sectors and align incentives for consumers, workers, and other key stakeholders.


disability civil rights; home and community-based services; home care; institutionalization; personal assistance services; workforce


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